Provider Demographics
NPI:1063430692
Name:PRUNEDA, AUGUSTIN C JR (OD)
Entity type:Individual
Prefix:
First Name:AUGUSTIN
Middle Name:C
Last Name:PRUNEDA
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 S ZARZAMORA ST
Mailing Address - Street 2:SUITE201
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78207-5255
Mailing Address - Country:US
Mailing Address - Phone:210-436-8808
Mailing Address - Fax:210-436-9163
Practice Address - Street 1:700 S ZARZAMORA ST
Practice Address - Street 2:SUITE201
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-5255
Practice Address - Country:US
Practice Address - Phone:210-436-8808
Practice Address - Fax:210-436-9163
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2139152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1335366-05Medicaid
TXT15386Medicare UPIN
TX1335366-05Medicaid
TXW27971Medicare UPIN